November 2017 Member of the Month

Member of the Month: Rolf Montalvo, MD

Houston FP found the heart of medicine

By Perdita Henry

posted 11.01.17

The heart. It’s a muscle that pumps and circulates blood through the body. One organ in the body that all the other organs depend on. When considered and taken care of, the heart can efficiently do its job, getting what’s needed to every other part of the body. When it’s taken for granted, the heart can become overtaxed, struggling to provide the body with all it needs. When the heart is ignored, the entire body is affected.

Rolf Montalvo, MD, grew up in Ecuador. He went on to attend medical school and was headed toward a career in cardiology. While completing an international rotation in Tampa, Florida, he got an up-close-and-personal view of the heart of medicine and how it functions. Rotating with a family medicine doctor changed his career path from the heart, to the heart of health care — and the rest, as they say, is history.

Montalvo took time away from his busy schedule to chat with me about his love of teaching, how he encourages family physicians in various stages of their careers, the challenges facing international medical graduates, and how a quick trip to a surrounding town can help him hit the reset button.

Did you grow up in Ecuador? My dad is Ecuadorian and my mom is Taiwanese. They met in Taiwan, where I was born, and we lived there for five years. Then we moved to Ecuador and that’s where I grew up. I consider myself more Ecuadorian than Taiwanese because that’s where I spent my formative years.

What made you want to come to the U.S. to practice? I attended Universidad San Francisco de Quito in Ecuador. Post graduate training there was very basic. We would study articles written by physicians in the U.S. and going to Tampa to work alongside the co-author I studied about back in Ecuador hit home. I wanted to learn from these guys. After rotating in Tampa, Florida, I realized that’s the kind of structure and education that one must get in order to be a good physician.

What inspired you to choose family medicine? I chose family medicine during my fourth-year rotation while I was in Tampa. I went to Tampa to complete an international rotation and I was more inclined toward cardiology. During my time there, I rotated with a family doctor who showed me what family medicine was all about. I saw how he interacted with families, kids, and dealt with a wide range of illnesses. He wasn’t just focused on one small thing. In fact, my favorite aspect is being able to treat almost all conditions that may affect someone and not being limited to just one area. He really had an interpersonal connection with his patients. That’s what changed my mind about pursuing cardiology.

Do you imagine you’ll spend your entire career in the U.S.? I think I will. It’s difficult to move away from the quality of education, the colleagues, the learning, and the opportunities that are always coming up. In addition to that, even though the U.S. has such advanced education and care, there are many challenges — serving the underserved populations, care inequalities, etc. — that must be met and I feel I can contribute positively.

We have a large and vibrant international medical graduate community in Texas. What are some of the challenges and advantages you have as an IMG? One challenge is being able to get into a residency program. It’s becoming more challenging each year. Residency slots stay the same while more IMGs are applying, U.S. medical school graduates are increasing, and medical schools increase their class sizes. It’s becoming tougher and tougher for IMGs to get into post-graduate training here in the U.S. Then once you’re in a residency program, it’s difficult to adapt to a more collaborative team approach to patient care. In the U.S. it’s really a team effort when it comes to patient care and this whole idea of hierarchy is fading away. The hierarchy was very much in existence where I trained in Ecuador. The attending was almost untouchable and you couldn’t disagree with him or her.

An advantage I would say — and this comes from my cultural background of being half Taiwanese and half Ecuadorian and having lived in both places — is being open to cultural differences. I try to be empathetic and understand where someone is coming from. I think that’s helped me a lot in the field of family medicine. Houston is such a diverse city and every day in clinic you encounter so many different people with different behaviors and motivations. It’s great to be able to understand them and that has helped a lot.

How do you think TAFP could better support its IMG members? When I joined TAFP as an IMG, becoming involved seemed unreachable. It almost seemed like you had to be an expert and have many years of practice to become involved in TAFP activities. One way to help IMGs is to let them know about it and make it easy for them to join committees and commissions as residents. When you are coming in as an IMG, you may assume it’s difficult or that the requirements are too extensive to participate in some activities. As program director, I saw that AAFP was sending a lot of communication, but from TAFP it wasn’t as much communication regarding IMGs. One thing is for sure, IMGs would really take advantage of the opportunity if they were clearly told “this is here for you.”

“One thing IMGs need to be aware of and to figure out is how to adapt to the collaborative approach.”

What inspired you to remain in academia as a family physician? In my third year of residency I really experienced what teaching and supervision was all about. After finishing residency, I was offered a faculty position. I took it immediately. For me it was a way to continue to teach in a more formal way and to continue to see patients. Then I was offered the position of residency program director in 2008, after a few years as a faculty member. That was a huge deal for me because it was a way to teach on an even broader scale. To affect the way teaching and supervision was done.

What inspires you in your current position? I’m currently the medical director of primary care. The physicians I work with are at various points in their careers, from new physicians to those who have been practicing for 20 years. It’s very easy for them to be swallowed completely by how busy it is — seeing patients quickly and not having time to do everything they need to do, especially once they finish residency. The joy I find in this position is that I get to help physicians keep things in perspective and educate them about what’s important in a population health aspect.

Is there a difference between what you encountered working with residents versus working with new physicians as they transitioned in their career journey? With residents, they are a little more naturally inclined to listen to you and follow a specific path as you guide them because they’re thirsting for that knowledge. You also have to be good about recognizing the different ways individual residents capture information. You may have to alter the message for specific residents so they actually get it.

With independent physicians, it’s more about being able to fit a new guideline or initiative into what they are already doing. Independent physicians already have a pattern of behavior — how they do their job and run their clinic — so the challenge becomes how to best incorporate the new initiative into their pattern so they don’t feel disrupted. For that to happen, I have to explain the main reason why something exists and why it’s being done. Once they get that, then they’re a little more open to how they can fit the initiative into their workflow.

Is there a piece of advice that you often find yourself giving the physicians you work with? I wouldn’t call it advice, but for physicians there are so many things they have to do in a day, I find myself always putting things into perspective and giving the reasons why something exists. They’ll wonder why they have to do something new or something different. So, I think of myself as being more of a translator. Initiatives are often spelled out dryly and it’s my job to make it relevant to them and to show how it improves their patient care and their practice.

What public health initiatives do you wish more FPs would champion? I favor initiatives where there’s no doubt about the evidence that exists. For example, colon cancer and breast cancer screenings have well established evidence about the effectiveness of screening and how many lives it can save. Even though most FPs are good about it and are aware of it, it’s easy to get bogged down with administrative tasks and everything else happening in the clinic, so there is still a lot of work to do when it comes to colon and breast cancer screenings. People really look to family docs to lead the way in these screening efforts.

Obesity is another one. While it’s not dependent on the physician treating the patient, the solution requires determining how good the access to care is; the access to education, opportunities for physical activities, safe neighborhoods, and cultural awareness. The solution has so many elements but I definitely want communities to be more aware about that.

There are so many things to take into consideration when working with physicians. How do you personally avoid burnout and do you share advice with the physicians on tackling burnout themselves? Personally, when I am feeling overwhelmed with work and worries I tend to exercise as a distraction or I might take a little road trip. I’ll leave early on a Saturday and come back late at night, or stay overnight in one of the smaller cities surrounding Houston or maybe a little further out. My favorite place to go is Lockhart because of the barbeque. I love going to Driftwood — again great barbeque — or I might go to San Antonio just to reset and get into a different environment — and it helps that Texas is so friendly. Everyone in every city is friendly. Usually that’s sufficient to reset things and come back with a new perspective.

When there’s a pressing project, I try to dive in head first. I complete it as efficiently as I can rather than avoid it. Knowing it’s something I can get done quickly means I can step out of that storm quicker rather than dragging my feet day to day hoping it’ll go away. It’s something I share with residents as well. When you’re feeling overwhelmed with call or had a lot of admissions overnight, when you feel like it’s something you cannot overcome, sometimes you just have to work through it and before you know it, you are done with it and on the other side. Same thing applies once you have graduated and are in your own practice. Also, disconnecting from my phone is essential — especially on weekends. I try to resist obsessively checking email. I do these things for myself and I share those tips with others.

TAFP’s Member of the Month program highlights Texas family physicians in TAFP News Now and on the TAFP website. We feature a biography and a Q&A with a different TAFP member each month and his or her unique approach to family medicine. If you know an outstanding family physician colleague who you think should be featured as a Member of the Month or if you’d like to tell your own story, nominate yourself or your colleague by contacting TAFP by email at tafp@tafp.org or by phone at (512) 329-8666. View past Members of the Month here.